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Copyright ERS Journals Ltd 1995
European Respiratory Journal
ISSN 0903 - 1936
Eur Respir J, 1995, 8, 1488–1493
DOI: 10.1183/09031936.95.08091488
Printed in UK - all rights reserved
Effect of regular inhaled beclomethasone on
exercise and methacholine airway responses in
school children with recurrent wheeze
N.J. Freezer, H. Croasdell, I.J.M. Doull, S.T. Holgate
Effect of regular inhaled beclomethasone on exercise and methacholine airway responses
in school children with recurrent wheeze. N.J. Freezer, H. Croasdell, I.J.M. Doull, S.T.
Holgate. ©ERS Journals Ltd 1995.
ABSTRACT: The role of airway inflammation in the pathogenesis of asthma in
childhood is uncertain. In the present study, 27 atopic and nonatopic children aged
7–9 yrs who had ≥5 episodes of wheeze and symptoms of exercise-induced asthma
(EIA) in the previous 12 months, performed a methacholine challenge and exercise
test on separate days at monthly intervals. The subjects had not received oral or
inhaled corticosteroids for 12 months prior to the study. The dose-response relationship to inhaled methacholine was expressed as the cumulative dose provoking
a 20% decrease in forced expiratory volume in one second (PD20). Forced expiratory volume in one second (FEV1) and peak expiratory flow (PEF) were measured
prior to the exercise test and at 0, 3, 5, 10, 15 and 20 min following maximal exercise. Following the first methacholine challenge and exercise test, the children were
randomized in a double-blind manner to receive inhaled beclomethasone dipropionate (BDP) 200 µg b.i.d. or a placebo b.i.d. from a Diskhaler® for 3 months.
All children were asymptomatic at the time of testing, and there was no significant change in the baseline FEV1 of any subject prior to either challenge throughout the study period. When compared to placebo, the bronchial responsiveness to
exercise and methacholine was significantly attenuated in the children who had
received inhaled BDP for at least 1 month. There was no relationship between the
bronchial responsiveness to methacholine and exercise. There was no significant
difference in the bronchial responsiveness to either stimulus in the atopic and
nonatopic children.
The results of this study suggest that immunoglobulin E (IgE)- and non-IgE-mediated airway inflammation are important in exercise- and methacholine-induced
bronchoconstriction in children with recurrent wheeze, although it is probable that
different mechanisms are responsible.
Eur Respir J., 1995, 8, 1488–1493.
The pathogenesis of asthma is not well understood;
however, evidence is accumulating that airway inflammation plays a central role [1]. Inflammation of the airways may increase bronchial responsiveness by lowering
the threshold of many stimuli to induce bronchoconstriction. How the inflammatory response translates to
airway hyperresponsiveness is a much debated topic;
however, geometric factors, such as mucosal swelling [2]
and uncoupling of the elastic retractile forces consequent
upon inflammatory expansion of airway adventitia [3],
are likely to be particularly relevant to the smaller airways of children with asthma.
Many exogenous stimuli may induce bronchoconstriction in asthmatic subjects. Methacholine induces
bronchoconstriction by "nonspecific" stimulation of the
bronchial smooth muscle in asthmatic and nonasthmatic
subjects; whereas, exercise is a "specific" stimulus inducing bronchoconstriction only in asthmatics. The method
University Medicine, Southampton General
Hospital, Southampton, UK.
Correspondence: N. Freezer
Paediatric Respiratory Medicine
Monash Medical Centre
Clayton
Victoria
Australia 3168
Keywords: Bronchial reactivity
childhood asthma
exercise-induced asthma
inflammatory mediators
inhaled corticosteroids
methacholine
Received: December 6 1994
Accepted after revision May 15 1995
by which exercise may induce bronchoconstriction is less
well understood, however, the weight of evidence is in
favour of exercise inducing hypertonicity of the airway
lining fluid [1], thereby activating primed mast cells for
autocoid secretion and triggering the early asthmatic reaction [4]. The release of short-acting inflammatory mediators may explain the persistence of bronchoconstriction
after removal of the initial stimulus; and depletion of
mediators has been advanced as one, but not the only,
mechanism to explain the refractory period that often follows exercise-induced asthma (EIA) [5]. The stimulation of muscarinic receptors may also be important in the
pathogenesis of EIA; however, the "muscarinic effect"
varies among subjects and may be variable in the same
subject [6]. EGGLESTON [7] reported a correlation between
the bronchial responsiveness to exercise and methacholine;
however, this has not been confirmed by other authors
[8].
EFFECT OF BDP ON BHR IN CHILDREN WITH RECURRENT WHEEZE
Recent bronchoalveolar lavage (BAL) [9] and bronchial
biopsy studies [10] in adults have demonstrated a significant reduction in airway inflammation and bronchial
reactivity to inhaled methacholine in adults with asthma
following regular inhaled corticosteroids. Although BAL
and bronchial biopsies have not been performed in children, inhaled corticosteroids have been reported to reduce
bronchial responsiveness to inhaled methacholine in children [11–14]. The finding that topical beclomethasone
dipropionate (BDP) can deplete the asthmatic airway
mucosa of its mast cell content, possibly by inhibiting
the production of cytokines from the T-cells [15], may
also provide an explanation for the protective effect of
this class of drugs against EIA.
The aim of the present prospective double-blind, placebo-controlled study was to determine whether inhaled
corticosteroids significantly reduce airway responsiveness to "specific" and "nonspecific" exogenous stimuli
in children with recurrent wheeze. The demonstration
of significantly reduced bronchial responsiveness to inhaled
methacholine and exercise in those receiving topical corticosteroids, would support the hypothesis that airway
inflammation is important in the pathogenesis of airway
responses to inhaled methacholine and exercise.
Patients and methods
Ninety five general practitioners at five health centres
in the Southampton area were approached and permission sought to study the children in their care. The names
and addresses of all children aged 7–9 yrs on 1st September
1991 on the practice lists of all participating practitioners were obtained, and a questionnaire was sent to each
family for completion by the parents. The questionnaire
was simple and enquired about the frequency of respiratory symptoms and treatment. If a reply was not
received after 2 weeks, a reminder was sent.
The children were invited to participate in this study
if they had ≥5 episodes of wheeze over the previous 12
months and they reported wheeze, cough, chest tightness
and shortness of breath after exercise. The respiratory
symptoms of each subject were confirmed by an interview with a physician at the time of enrolment. No children had received oral or inhaled corticosteroids over the
12 months prior to the study.
Following enrolment, the atopic status and bronchial
responsiveness of each subject to methacholine and exercise was determined. Antihistamines were withheld for
14 days prior to allergen skin-prick testing. Beta2-agonists
were withheld for 6 h, sodium cromoglycate for 8 h,
and theophylline for 12 h prior to the methacholine challenge or exercise test. The study was approved by the
Southampton Joint Ethics Committee and informed consent was obtained from a parent or guardian.
1489
histamine dihydrochloride used as the positive control.
A skin-prick test was considered to be positive if the
diameter of induration was ≥3 mm greater than the saline
control.
Methacholine challenge
Methacholine challenges were performed using handheld DeVilbiss No. 40 glass jet nebulizers (DeVilbiss
Co., PA, USA) according to the method of YAN et al.
[16]. Doubling doses of methacholine diluted with phosphate buffered saline from 0.025–6.4 µmol were inhaled
until the forced expiratory volume in one second (FEV1)
1 min post-inhalation fell to less than 80% of the postsaline value, or the highest concentration had been reached.
If the FEV1 was close to 80% of the post-saline value,
the FEV1 was repeated 3 min post-inhalation before the
next dose was delivered. The dose-response relationship
to methacholine was determined and the cumulative concentration proving a 20% decrease in FEV1 (PD20) was
calculated by interpolation or extrapolation. Prior to randomization, bronchial challenges to methacholine were
performed on two consecutive days to assess the repeatability of PD20 using this protocol.
Exercise testing.
A standardized exercise test [17] was performed on
asymptomatic children if their baseline FEV1 was ≥70%
of the predicted value for their height [18]. They were
studied at approximately the same time of day using a
cycle ergometer (Jaeger ER900, Germany). A noseclip
was worn and the children breathed dry air (water content ≤4 mL·L-1) at room temperature (20–24°C) from a
Douglas bag. The workload was increased from 25 W
in 20–25 W increments at 1 min intervals to a maximum
of 150 W, depending on the age, sex and physical fitness of the child [19].
Heart rate was monitored with an electrocardiogram
(S&W Medico Teknik A/S, Alertslund, Denmark) and
oxygen consumption (V' O2) was displayed in real time
(Ametek Thermox Instruments Division, Pittsburgh, PA,
USA). The test was conducted for at least 5 min and
terminated when the child was exhausted, the heart rate
was ≥170 beats·min-1 and the V' O2 was ≥30 mL·kg-1·min-1
for at least 1 min [19]. The workload for each exercise
test was determined by monitoring the patients heart rate
and oxygen consumption in real time.
A dry wedge spirometer (Vitalograph®, Buckingham,
UK) and a paediatric Wright peak flow meter were used
to measure the FEV1 before exercise and at 0, 3, 5, 10,
15 and 20 min following exercise. At each time-point,
the highest of two FEV1 values within 100 mL of each
other was recorded. The repeatability of the post-exercise fall in FEV1 was assessed prior to randomization.
Atopic status
Study protocol
Atopic status was assessed by skin-prick testing for
Dermatophagoides pteronyssinus, mixed grass pollens
and cat dander (Soluprick®, ALK, Denmark), with
Following the first exercise test and methacholine challenge, the subjects were randomized into groups of four
N.J. FREEZER ET AL.
in a double-blind manner, to receive inhaled beclomethasone dipropionate (BDP) 200 µg b.i.d. or placebo b.i.d.
via a dry powder delivery device (Diskhaler®). Following
randomization, three further exercise tests and methacholine challenges were performed at monthly intervals
on separate days. Compliance with the study medication was assessed by counting the returned used BDP
and placebo Diskhaler® disks. Because of the known
marked carry-over effect of corticosteroids in asthma, the
study was conducted as a parallel group, rather than as
a cross-over design.
Statistical analysis
Statistical analyses were performed using Minitab and
SPSS-X statistical software. Analysis of variance was
used to compare the fall in FEV1 and peak expiratory
flow (PEF) post-exercise and the log PC20 values of the
methacholine challenge of the steroid and placebo groups.
Student's t-test was used to compare the baseline FEV1
and PEF of each subject prior to each exercise test or
methacholine challenge. The null hypothesis was rejected
if the value of p was less than 0.05. The repeatability
of the post-exercise fall in FEV1 and PD20 methacholine
was assessed prior to randomization. The coefficient of
repeatability for FEV1 was calculated using the method
of BLAND and ALTMAN [20], and the repeatability of PD20
methacholine was calculated using the method of CHINN
[21].
Results
Of the 5,727 questionnaires distributed 4,830 (84%)
were returned. One hundred and forty one children had
not received corticosteroids and had ≥5 episodes of wheeze
in the previous 12 months. Thirty five of these children
also reported cough, wheeze, chest tightness and shortness of breath following exercise. Of the 31 children
who were enrolled, 27 children completed the study (22
males and 5 females). Four were withdrawn at parental
request following the first exercise test.
Table 1. – Demographic and pulmonary function data
prerandomization
Variable
Pts n
Sex M/F
Age months
Atopic n
Baseline FEV1 L
% pred
Baseline PEF L·min-1
% pred
Log PD20 methacholine
Max fall in FEV1
post-exercise %
BDP
Placebo
14
13/1
99±11
6
1.59±0.33
95
253.0±33.9
97
1.98±1.5
7.7±6.8
13
9/4
101±10
9
1.57±0.31
95
252.5±37.3
97
1.50±1.7
6.5±9.1
Values are presented as mean±SD. Pts: patients; FEV1: forced
expiratory volume in one second; % pred: percentage of predicted value; PEF: peak expiratory flow; PD20: dose provoking a 20% decrease in FEV1; BDP: beclomethasone dipropionate.
p>0.05 (NS) for all variables.
Table 2. – Other asthma medications
Asthma medication
Total
β2-agonist, p.r.n.
β2-agonist, regularly
Sodium cromoglycate
Theophylline
Pts n
(BDP/placebo)
16
4
3
1
(7/9)
(3/1)
(2/1)
(0/1)
Note: a patient may be taking more than one medication. Pts:
patients; BDP: beclomethasone dipropionate.
Fourteen children received inhaled BDP and 13 received
placebo. The mean compliance with the study medication of the group receiving BDP was 86%. The subjects
in the corticosteroid and placebo groups were well-matched
for demographic data and indices of pulmonary function
(table 1). Four children received other regular asthma
medications and 16 children used inhaled salbutamol as
required for the relief of asthma symptoms (table 2).
These medications were not withheld during the study.
Bronchial hyperresponsiveness
Methacholine. For each subject, the baseline FEV1 did
not change significantly prior to each methacholine challenge. Prior to randomization, 21 subjects exhibited
bronchial responsiveness to inhaled methacholine. Twelve
of these children subsequently received BDP and nine
received placebo. There was no significant difference
in the mean PD20 of the two groups (p=0.5), or the incidence of atopy. The 95% confidence interval for the
measurement of PD20 was two doubling dilutions.
The methacholine-induced bronchial responsiveness
was significantly reduced in the group who received BDP
for at least 4 weeks (p<0.05). This effect was maintained whilst the subjects were receiving the study medication (fig. 1).
Exercise. All patients achieved the criteria for maximal
exercise during each exercise test, and for each subject,
5
Log PD20 methacholine µmol
1490
NS
p<0.05
p<0.05
p<0.01
0
-5
0
2
1
Treatment months
3
Fig. 1. – Cumulative log PD20 methacholine (µmol) vs duration of
treatment. Values are presented as mean±SEM. PD20: dose of methacholine provoking a 20% decrease in forced expiratory volume in one
second; NS: nonsignificant. —●—: beclomethasone dipropionate;
—❍—: placebo.
1491
EFFECT OF BDP ON BHR IN CHILDREN WITH RECURRENT WHEEZE
a)
100
90
90
0
0
5
10 15
3
0
Time post-exercise min
Pre
20
5
10
15
20
5
10 15
3
0
Time post-exercise min
20
3
0
Time post-exercise min
120 Three months
d)
Two months
p<0.01
110
p<0.05
100
80
120
% Baseline FEV1
110
80
Pre
c)
% Baseline FEV1
NS
% Baseline FEV1
% Baseline FEV1
110
120 One month
b)
120 Pre-randomization
100
90
110
NS
100
90
80
80
0
0
Pre
5
10 15
3
0
Time post-exercise min
Pre
20
Fig. 2. – Post-exercise FEV1 pre-randomization and following treatment with BDP or placebo. Values are presented as mean±SEM.
Note that the vertical axis are cut of from zero. FEV1: forced expiratory volume in one second; BDP: beclomethasone dipropionate; NS: nonsignificant. —●—: BDP; —❍—: placebo.
in FEV1 post-exercise (r=-0.2; p=0.40) (fig. 3). The 3
children who were most responsive to methacholine (PD20
<0.1 µmol) had a ≤5% fall in FEV1 post-exercise.
30
Exercise-induced fall in FEV1 %
the baseline FEV1 did not change significantly prior to
each exercise test. The maximum fall in FEV1 was
observed at 3 min post-exercise, and the coefficient of
repeatability for FEV1 was 2.2%. Prior to randomization, no significant difference was found between the
post-exercise fall in FEV1 when the corticosteroid and
placebo treatment groups were compared (p=0.7) (fig.
2a). When analysed in terms of atopic status, there was
no significant difference in the maximum post-exercise
fall in FEV1 between the children who were skin test
positive and those who were skin test negative (p=0.9).
Eight out of 27 children experienced a >10% fall in FEV1
following exercise, five being atopic and three non-atopic
(fig. 3).
Inhaled BDP had a marked effect in reducing the exercise-induced fall in pulmonary function. After 1 and 2
months of treatment with inhaled BDP, the maximum postexercise fall in FEV1 was 0.0±1.7 (SD) and 0.0±1.6%,
respectively, compared to 6.0±3.5 and 11.0±3.0% in the
placebo group (analysis of variance (ANOVA) p<0.05)
(fig. 2b and c). Following 3 months of treatment, a trend
in protection against exercise-induced fall in spirometry
persisted; however, it was no longer significantly different
from the placebo group (p=0.09) (fig. 2d). Similar results
were obtained using PEF as the measure of lung function.
No significant relationship could be established between
the cumulative PD20 methacholine and the maximum fall
25
20
15
10
5
0
-2.0
-1.0
0.0
2.0
1.0
Log PD20 methacholine µmol
3.0
Fig. 3. – Individual patient data for post-exercise maximal
fall in FEV1 vs log cumulative PD20 methacholine (µmol) in
atopic and nonatopic subjects, at run-in into the study. For
abbreviations see legends to figures 1 and 2. ●: atopic; ❍:
nonatopic
N.J. FREEZER ET AL
1492
Discussion
The diagnosis of asthma in children is based on a clinical history and physical examination, and is not dependent on the demonstration of bronchial hyperreactivity
to an inhaled exogenous agent or exercise test. The selection of the subjects for the present study was deliberately based on a history of recurrent wheeze (including
wheeze following exercise) and not the PD20 methacholine or the degree of bronchoconstriction following a
standardized exercise test. Most studies on asthma in
childhood have been conducted on subjects selected from
hospital clinics with severe disease, and, therefore, the
results of this study may not be directly comparable.
As the diagnosis of asthma may be underestimated [22,
23] we deliberately selected children from the community on the basis of a positive response to a respiratory
questionnaire, without making the prior assumption of a
diagnosis of asthma. Although all of the children enrolled
in this study had clinical asthma, only one third of those
who entered the treatment phase had been diagnosed with
asthma, further emphasising the under diagnosis and,
therefore, undertreatment of asthma, originally highlighted
by LEE et al. [22]. In order not to confound the interpretation of the therapeutic intervention, symptomatic
children who had received oral or inhaled corticosteroids
were deliberately excluded from the study.
In asthmatics, the attenuation of bronchial responsiveness to exogenous stimuli with the use of inhaled corticosteroids has been reported previously [11–14, 24–27].
These authors conclude that airway inflammation may
be important in the pathogenesis of the increased bronchial
responsiveness characteristic of asthma. The results of
the present study confirm that regular inhaled corticosteroids attenuate methacholine- and exercise-induced bronchoconstriction in children with recurrent wheeze, supporting
the hypothesis that airway inflammation may be important in the pathogenesis of bronchoconstriction in these
children.
Although all of the children in the present study had
symptoms consistent with exercise-induced bronchoconstriction, only 30% had unequivocal exercise-induced
bronchoconstriction, with a fall in FEV1 greater than 10%
following maximal exercise. Despite the mild nature of
EIA in many of the subjects, regular inhaled corticosteroids significantly attenuated exercise-induced bronchoconstriction. The effect of regular inhaled corticosteroids
on exercise-induced bronchoconstriction appeared to be
fully manifested after 1 month of treatment; however,
the effect appeared to diminish after 3 months.
In the same subjects, BDP had a sustained inhibitory
effect on methacholine-induced bronchial responsiveness.
This suggests that a mild degree of tolerance may have
developed when exercise was the stimulus used to provoke
bronchoconstriction, and further long-term studies are
required to establish whether tolerance to inhaled corticosteroids may occur. The discrepancy in the attenuation
of bronchoconstriction following methacholine- and exercise-induced bronchoconstriction is unlikely to be due to
lack of compliance with the study medication, as each
subject performed both challenge tests, and a careful
check of the number of empty BDP Diskhaler® blisters
returned at each assessment showed no decrease in patient
compliance. The possibility of a type 2 error cannot be
excluded.
Of particular interest was the absence of any correlation between methacholine- and exercise-induced bronchial
responsiveness. Indeed, the three children with the most
responsive airways to inhaled methacholine (PD20 <0.1
µmol), had ≤5% falls in FEV1 following exercise (fig.
3). Whilst in related populations of subjects with asthma, usually acquired from hospital clinics, methacholine
and exercise have been positively correlated [7], a recent
study on more representative symptomatic children [8]
failed to confirm the association, suggesting that methacholine- and exercise-induced bronchoconstriction reflect
independent components of the disordered airway function in asthma.
It has also been implied that most asthma (including
exercise-induced asthma) in childhood is associated with
atopy [28, 29]. In the present study, the response to
exercise and inhaled methacholine did not differ in the
atopic and nonatopic subjects (fig. 3), suggesting that
bronchoconstriction in children with recurrent wheeze
may occur in the absence of atopy.
In conclusion, the present study suggests that airway
inflammation is important in the airway response to exercise and inhaled methacholine in children with recurrent
wheeze. The marked efficacy of regular BDP in preventing bronchoconstriction induced by exercise and
methacholine in children is an important clinical observation and has direct relevance to the recently published
guidelines for the management of childhood asthma [23],
where a strong emphasis is placed on preventative antiinflammatory therapy. Whether children with relatively
mild episodic disease should be treated with regular topical corticosteroids is a debatable issue in relation to compliance and systemic side-effects, but it would appear
from this study that symptomatic school children who
experience significant exercise-induced bronchoconstriction could benefit greatly from this form of treatment,
thereby diminishing their need for the repeated use of
symptom relieving bronchodilators.
Acknowledgements: The authors gratefully acknowledge
the support of J. Hall (Allen and Hanbury, UK) for providing the study medication and the grant-in-aid to support this
work. They are also most grateful to S. Smith, J. Schreiber
and S. O'Toole for their assistance.
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